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Anesthesia without Borders with Erica Alcibiade · Style Points

0:10
and welcome to Style Points. Today, our guest
0:13
is going to talk to us about her experience doing
0:15
volunteer anesthesia in environments where resources
0:18
are particularly scarce. Dr. Erica Alcibiade,
0:23
who once told me to pronounce her name using
0:25
the letters L, C, B, A, and D, is an assistant
0:28
professor of anesthesiology and former chief
0:31
resident of our program here at the University
0:33
of Cincinnati. After graduation, she did her
0:36
fellowship in regional anesthesiology and acute
0:38
pain medicine at Johns Hopkins before coming
0:41
back to our group at UC. When she isn't practicing
0:44
aerial yoga, she's planning her next trip to
0:46
some amazing locale where she takes pictures
0:48
of herself eating snacks next to a waterfall.
0:51
Erica, thank you so much for joining us. Absolutely.
0:54
So I've got a question for you, which is pretty
0:58
commonplace at this point. I've asked it to many,
1:00
many people over time. But it's our dinner question.
1:04
So if you could have dinner with anyone in the
1:07
world, could be somebody from the past or even
1:09
from fiction, who are you having over for dinner
1:11
and why? I've always traditionally been really
1:14
bad at answering this question. You know, all
1:17
of my guests say the exact same thing. So I'm
1:20
interested in your bad answer as well. But I
1:23
have two and I can't decide which is the more
1:25
accurate answer. So I'm going to give you both.
1:27
Excellent. The first is my... grandfather on
1:29
my dad's side uh he passed away when my dad was
1:32
a teenager and came over to the us from italy
1:34
so i feel like he would have some really cool
1:36
stories both about you know family and some historical
1:39
stuff uh so i think that would be really cool
1:42
to find out and figure out you know what terrible
1:44
things my dad was doing as a teenager so you
1:47
could use this blackmail against him exactly
1:49
excellent And then my other answer is John Muir,
1:53
because I love doing the national parks and outdoorsy
1:56
stuff. And I think he would have some really
1:57
cool stories about what he saw that used to exist
2:00
prior to everything becoming modernized. That
2:04
makes a lot of sense. And that sort of plays
2:06
into what we're going to talk about today, which
2:09
is essentially you being a world traveler and
2:13
somehow turning that into something that you
2:15
can do at work as well as on your own free time.
2:20
Let's talk about that. How did you get into doing
2:23
what it is you do? So I wish I had a, you know,
2:28
great story, but it's just kind of a culmination
2:30
of everything that I love to do. As you mentioned,
2:33
I love to travel and I always knew I wanted to
2:36
take care of resource limited areas. I went to
2:39
medical school in East Tennessee where there
2:42
is not a whole lot of rural medicine population
2:45
being taken care of. So we used to do clinics
2:48
for them and just combining some of the things
2:51
that I love. International mission trips have
2:54
become something that I am. super passionate
2:55
about. It's one of the reasons that I did a regional
2:58
and acute pain fellowship. I want to be able
3:00
to teach regional in resource -limited areas,
3:04
places where general anesthesia is not necessarily
3:07
safe, that people can have surgeries with much
3:10
less risk. So is regional safer somehow than
3:14
general anesthesia? Let's walk through that.
3:17
Yeah. A lot of the studies that look at resource
3:20
-limited areas in anesthesia show that there's
3:23
just not well -trained anesthesia providers and
3:26
in some areas, not anesthesia providers at all.
3:29
So managing airways and respiratory status is
3:32
one of the leading causes of morbidity in these
3:35
areas. So if you can avoid needing to manipulate
3:38
an airway and knock out someone's arm or leg
3:40
or, you know, whatever it is that they can have
3:43
surgery comfortably without needing general anesthesia,
3:46
it can actually be much safer for them in the
3:48
long run. So that's what inspired you to do your
3:50
fellowship? It did. How was your fellowship geared
3:54
towards that what sorts of techniques things
3:57
did you learn did you gain expertise in that
4:02
made this easier for you? One of the reasons
4:05
I chose to go to Hopkins for fellowship was because
4:08
they have a lot of global connections already.
4:10
And I had asked during my interview process about
4:13
the ability of spending my elective time doing
4:16
mission trips and doing global health work. And
4:18
they were very supportive of it. Although they
4:20
didn't have a program involved for regional at
4:23
the time, they were very supportive in figuring
4:25
out how I could do that. And I was actually able
4:27
to spend two weeks in Ghana. and another week
4:31
in Uganda during fellowship, both on regional
4:36
-based trips, one through ASRA and another through
4:39
another local group that one of the surgeons
4:41
that we worked with was involved in. So I got
4:44
to go and do and teach blocks and be really involved
4:47
in kind of more a regional -focused trip rather
4:49
than a generally anesthesia -focused trip. So
4:51
it was really cool to see all of that. I had
4:54
the privilege of being and attending while you
4:57
were here in training, and I remember you as
4:59
a trainee. And you were always somebody who was
5:02
really steady and good with blocks and good with
5:06
your needlework. So I think it surprised some
5:08
of us when we thought about you doing a regional
5:11
fellowship. But that makes it make a lot more
5:15
sense for me, at least in my mind, why you would
5:17
want to do a regional fellowship. It wasn't necessarily
5:19
that you needed any extra skills with a block
5:22
needle, which, again, you were always great at.
5:26
But more about... gaining a global perspective
5:29
on things yeah yeah and that was a large part
5:32
of you know doing the fellowship learning how
5:33
to kind of teach these things better um to trainees
5:36
that you know have never done a block have never
5:38
even seen an ultrasound in some of these locations
5:40
so let's talk a little bit more about what you
5:46
do as part of your work here in all these different
5:48
countries? Do you have some different buckets
5:50
that you like to put things into? Yeah, every
5:52
trip's a little bit different. You know, there's
5:55
teaching trips, there's doing trips, there's,
5:57
you know, educational things. So here at UC,
6:00
we have two trips that we have gone on multiple
6:04
times, one being started by Mike Howershock.
6:08
with Partners for Medical Relief in Belize. That
6:11
is more of a doing with a slight component of
6:14
teaching trip that we regularly take residents
6:16
on. That is more of a general anesthesia type
6:19
trip. It's mostly with ENT surgeons and general
6:24
surgeons. So it just leads to more general anesthesia
6:28
happening for those type of procedures. And then
6:31
in Uganda, it's kind of a combination of both
6:33
doing and teaching, which is another trip that
6:36
Josh tried. had gotten involved in with one of
6:39
our surgeons, Dr. Zender, with his nonprofit.
6:43
So that's a little bit more doing and teaching
6:46
simultaneously. They tend to bring trainees from
6:49
all over the country to the hospital that we
6:51
happen to be at so that their trainees can learn
6:53
from us. And they have anesthesiologists as well
6:56
as what they call medical officers there, which
6:58
kind of function similar to how we think of like
7:00
CRNAs and AAs here. But a lot of them practice.
7:04
a little more independently just because of lack
7:06
of providers throughout the country. Sure, that
7:09
makes a lot of sense. So let's talk about sort
7:13
of start to finish what one of these trips looks
7:16
like, generally speaking. I'm sure that with
7:19
these longstanding trips, you have a date in
7:22
mind that you're going to go. What does all the
7:25
logistics look like between having the idea and
7:29
actually going and doing? Uh, there's a lot that
7:32
goes into it that, you know, people don't necessarily
7:34
think of or recognize. Um, Mike has got me a
7:37
lot more involved in the planning stages of the
7:39
Belize trip. I'm actually now on the board of
7:40
partners for medical relief and I'm involved
7:43
in a lot of their planning and logistics and
7:45
figuring that out. Um, so, you know, things from
7:49
ordering medications, ordering supplies, what
7:51
do we think we'll need? Who's coming with us?
7:53
How do we get everyone there safely? You know,
7:56
Most of these countries, whenever medical trips
7:58
come in, go through the supplies that you're
8:00
bringing in, make sure they're not expired, make
8:02
sure that there are things that are safe that
8:03
they would use on their patients, which is totally
8:05
appropriate. But it's common questions that I
8:07
get here is, hey, we have all this stuff expiring.
8:09
Can we just give it to you for a mission trip?
8:10
And while I wish we could take it. the answer
8:12
isn't always yes um so it's just little things
8:16
like that how do you have a big enough team how
8:18
do you account for if somebody gets sick making
8:20
sure you have you know a backup plan in that
8:22
scenario if someone can't go last minute if a
8:25
flight gets delayed What medicines do you want
8:28
to have with you? What medicines can you readily
8:31
obtain and take into places? Obviously, we're
8:33
not going to, you know, buy fentanyl off the
8:35
street and take it down to a foreign country
8:37
with us. So that's something we have to rely
8:39
on getting there and knowing, you know, their
8:42
health system can help us as well. So making
8:44
connections within whatever city hospital system,
8:48
even government that you're, you know, going
8:51
through can really help safely get your group
8:54
there, do the work that you need to do. connect
8:57
with the people you want to educate i don't actually
9:00
have any personal experience with buying fentanyl
9:02
off the street and i have never thought about
9:05
the logistics involved with getting controlled
9:08
medicines in a foreign country yeah how do you
9:13
do you send an email how does how does that work
9:15
how do you how do you start to think about obtaining
9:18
something like that yeah um in belize which is
9:21
where i have like the most experience you know
9:23
getting um kind of the medications and the involvement
9:26
in that is we actually use the hospital system,
9:29
uh, that we work through is, um, narcotics. Um,
9:32
so we have what we lovingly call the drug lady,
9:35
uh, and she comes every morning with a locked
9:38
box, um, that has fentanyl and morphine in it,
9:42
as well as, um, usually a couple of pills and
9:44
things that they can like coding, uh, Tylenol
9:46
number threes that they can send patients home
9:48
with, um, if they so desire. Um, and we sign
9:52
it out from them. And at the end of the day,
9:54
she comes back around and takes whatever vials
9:56
are unused and redocuments it in her book and
9:59
puts how many milligrams each patient got and
10:02
who it went to. And they're all the glass ampoules.
10:06
So one of the big things I have to teach trainees
10:07
is not to throw that glass ampoule in the sharps
10:10
bin because she wants it back. She wants proof
10:12
that that is gone. So many times trainees are
10:16
digging. With, you know, long forceps or something
10:21
to get a fentanyl vial out of the sharps container.
10:23
So that's always a learning curve. That sounds
10:26
actually like a more intensive wasting process
10:28
than I maybe would anticipate for that sort of
10:31
environment. In Africa, the experience I've had
10:34
is just one of the other providers gets it and
10:38
we use it. I don't know what waste process we
10:40
go through there. Well, that makes sense. Okay,
10:44
so. What other supplies do you need for a trip
10:48
like this? And how does one obtain those things?
10:51
A lot of it is, you know, things that we think
10:54
of as, you know, disposable, reusable things,
10:56
endotracheal tubes, needles, syringes, oral airways,
11:00
just anything you would think of for it. normal
11:03
anesthetic, even IVs and tubing. And typically
11:05
we don't take fluids with us because they're
11:07
heavy. That's something else we buy from their
11:08
hospital system to use just because it's hard
11:11
to ship fluids. But we'll often take the medicines
11:15
with us and things. There are a couple of places
11:18
within the city that do, I guess, donation -based
11:22
things that people can donate from hospital systems.
11:25
There's Matthew 25 Ministries, and then there's
11:28
a place down in Louisville. I can't remember
11:30
currently, but they get a lot of medical supplies
11:33
and you can send them kind of a wish list or
11:36
go dig through some of their bins yourself. And
11:39
then they are able to you buy it for a very cheap
11:43
price in comparison to what you would buy on
11:45
like the medical market to take with you. So
11:48
are you packing that all into a checked bag?
11:51
How does that work? Checked bags. or duffel bags
11:56
or whatever you know you can get um this last
11:58
trip to belize that i went on um The first week
12:02
where we take down a majority of the supplies,
12:04
the second week they bring some more supplies,
12:07
but a lot of the stuff goes down the first week
12:08
just to make sure we have everything that we
12:09
need. I think we had 75 checked bags that were
12:13
going with us. Whoa. Are you carting these through
12:16
the airport? How does this work? Are you taking
12:19
multiple trips from your car? It's a big group.
12:22
They have people, you know, there's a couple
12:25
houses that do the packing of the supplies, and
12:28
then they tell people, hey, start coming to pick
12:30
up. checked bags. Um, so people will stop by
12:33
all these, you know, different people's houses
12:35
and pick up bags and it's your responsibility
12:37
to get them to the airport and they check you
12:40
in, in one big group and scan them all through.
12:43
And somehow I got involved in that process last
12:45
year. So I was, you know, handing passports back
12:48
to everyone and counting bags and doing all sorts
12:50
of crazy stuff. So it was kind of cool to be
12:52
on that side of things, but it was definitely
12:54
very labor intensive. I would hate to be. behind
12:58
you in line oh yeah at the airport they specifically
13:01
gave us our own um our own uh ticket counter
13:04
and made everyone else go elsewhere wow yeah
13:07
i can imagine that is that some is that a situation
13:10
where they sort of know that you're coming and
13:12
are doing this or is it just you show up and
13:15
they're like oh great Probably a little bit of
13:18
both. I know Mr. Kirby that organizes the tickets
13:22
and that kind of stuff had messaged American
13:25
back and forth about some of the logistics and
13:27
getting some approvals for free bags just since
13:31
it was a mission trip and that kind of stuff.
13:33
So they had maybe an idea, but I doubt the ticket
13:35
counter realized that that was happening until
13:38
we showed up. Okay, so you've packed all of your...
13:42
drugs and equipment you've gotten on the plane
13:45
i assume that you're massively jet lagged um
13:49
you get there then what what happens um well
13:53
kind of depends you know which trip it is the
13:55
belize trip is about a two hour drive from the
13:57
airport to where we're actually going to be working
14:02
The Uganda trip, which is my next most frequent
14:04
trip, is about an hour from the airport. So you
14:07
have to wait for all of those 75 or however many
14:10
bags you're checking to come through the terminals,
14:12
put them all on the thing, load them up into
14:14
vans. You know, 12 passenger vans are typically
14:17
what we travel in. Um, so however many of those
14:20
you need for however many people are going, Belize,
14:22
we often have like six, 12 passenger vans packed
14:26
full of people and bags, um, on the way up to
14:29
Corozal where we typically are based. Um, so
14:34
you, you know, you land, you wait for everyone
14:36
to get their stuff, um, personal bags and all
14:39
the checked equipment bags. Uh, if somebody goes
14:42
and gets the vans, I don't take responsibility
14:44
for driving those. That seems like too much for
14:46
me. That was going to be my next question. Are
14:48
you driving? Someone from the trip is. I have
14:52
yet to volunteer for that role. You do all the
14:56
other stuff. You don't need to drive the van.
14:58
Yen Shay once made me bounce my head off of the
15:00
ceiling when I was sitting on the floor of the
15:02
back of the van. So that was on purpose, but
15:06
you know. Excellent. Well, I imagine when you're
15:09
packed in tight with all those 75 bags, it's
15:12
probably inevitable. Yeah. Flat tire the last
15:16
time we were driving to the hospital in one of
15:18
those vans. So that was fun Okay, so tell me
15:20
the flat tire story though There's you know,
15:23
six van six white vans just following each other
15:25
and all of a sudden we see like some smoking
15:28
coming From the one really go what's going on
15:31
and they pull off and we realize they have a
15:33
flat tire So everyone just kind of you know files
15:35
off to the side of the road since we're traveling
15:37
in a large caravan and I didn't know this, but
15:41
apparently there's spare tires like tacked up
15:43
to the bottom of a lot of these vans. But between,
15:48
I think, four vans, we could only find one tire
15:51
that A, we could get off or B, that wasn't also
15:53
flat and destroyed. So they sent a bunch of us
15:59
on our merry way. They sent another van from
16:01
the rental company up to meet them and they eventually
16:05
made it to the hotel and the hospital. Excellent.
16:09
Okay, so you get there to the area where the
16:12
hotel and the hospital is. What does that...
16:16
hospital operating room look like? How is it
16:19
different from what we have here? So the hospital
16:22
that we go to in Belize is the Corazal Hospital.
16:25
It is in northern Belize and just across the
16:29
Mexico border. The system or the hospital that
16:32
we typically do our surgeries in there does not
16:35
have functional operating rooms unless a team
16:37
is there volunteering. So they are just used
16:39
for volunteer teams. About 45 minutes away is
16:42
a city called Orange Walk where they do their
16:45
um, actual surgeries for that area. Um, which
16:50
I actually personally haven't been to, but some
16:52
of our other colleagues have, have been there.
16:53
They've done surgery there in the past, just
16:55
depending on what's going on. Um, so I've never
16:57
seen those operating rooms, but the ones in cortisol,
17:00
uh, there's two ORs that we use. Um, you know,
17:05
they're big white rooms with whatever equipment
17:08
that people have left behind. Um, our group has
17:12
actually, um, Found I don't remember where they
17:15
came from, but had donated and had anesthesia
17:18
machines donated in the last couple of years.
17:22
So they're actually newer than the ones that
17:24
I started going there with. Mike knew very well
17:27
how to use the I believe he calls them narco
17:29
meds machines that are sitting now in the back
17:32
hallway that we use as a display for the residents
17:34
when they come down to see what anesthesia machines
17:36
used to look like. But now we have. some more
17:42
updated equipment um there's you know a hospital
17:46
bed uh or our bed and each one um that is not
17:50
electronic it does not go up and down most of
17:53
the time it has a foot pedal to raise and lower
17:55
that that might work sometimes uh so you're kind
17:59
of just working with the equipment that is readily
18:02
available when you were using those older machines
18:06
back back a few years ago what were some of the
18:09
biggest differences between those machines and
18:11
maybe the slightly more updated machines we have
18:13
here um definitely the co2 absorbent was different
18:16
it was just one of those ones that you dumped
18:18
pellets in rather than had the exchangeable canisters
18:21
that we now take down with us for you know the
18:24
trips um but it was just a very um saturated
18:29
co2 absorbent so you never really knew exactly
18:32
when your gas was gonna wear off the gas analyzer
18:34
was a little questionable um The machines also
18:38
progressively the screen that showed like the
18:43
title volume and your minute ventilation and
18:45
that kind of stuff throughout the week that I
18:47
was there as a resident when Chris and Mary were
18:49
there also just progressively kept getting blacker
18:53
and blacker up the screen as the week went on.
18:55
So at the end of the trip, you could only see
18:57
where it said the date and time, which wasn't
18:59
accurate anyways. I would imagine that would
19:04
be the least helpful thing to know is the date
19:06
and time when you're trying to anesthetize somebody.
19:09
Yes. So what we're dealing with is doing anesthesia
19:13
in this completely resource -limited environment.
19:17
What else besides the machine being a little
19:19
out of date is different? Yeah. So with Belize,
19:23
we take pretty much everything with us. So we're
19:25
able to tailor it a little bit better to what
19:27
we're more used to here in the U .S. You know,
19:30
we take the meds that we can get with us. Some
19:33
of the things that are harder to get, obviously,
19:35
the controlled substances. For whatever reason,
19:38
it's hard to get phenylephrine ordered, but we
19:41
can usually get ephedrine ordered, which is wild
19:43
to me considering it's a controlled substance
19:45
here in Ohio, but it's not everywhere. Just knowing
19:49
what meds you have, how much of those meds you
19:51
have, because it's a finite resource. However
19:54
much propofol you take with you is how much you
19:56
have available for that week or two weeks, depending
20:00
how long you're going for. Also sizing of things.
20:04
We can take a bunch of endotracheal tubes down,
20:07
but if we end up doing a bunch of peds and only
20:08
have a few peds -sized things, you can't do any
20:13
more peds safely. So just different things to
20:15
plan for. A colleague down there that has a basement,
20:21
which is apparently rare in Belize, but he keeps
20:22
a lot of equipment in his basement for us that
20:25
he brings up in a trailer every time we come
20:27
to visit. So we have a lot of disposable supplies
20:31
kind of tucked away in there so that we know
20:33
we have some endotracheal tubes and things like
20:35
that left there. And we donate a lot of it to
20:38
their local teams as well whenever they ask for
20:42
certain supplies. That way we can always bring
20:44
more the next time. What about monitoring? Are
20:47
your monitors significantly different than we
20:49
use here? I wouldn't say significantly different,
20:53
but intermittently functional might be a correct
20:57
wording. In one of the ORs, we use two different
21:02
monitor screens to get all of the vitals we are
21:05
used to having. I think one of them has the blood
21:07
pressure. One of them has the pulse ox and end
21:09
tidal. And I don't remember which has the EKG
21:12
on it. But we have to use two different monitor
21:15
screens and two different sets of cables to get
21:17
the appropriate vitals that we would normally
21:20
have here during surgery. We also have portable
21:24
monitors out in PACU. There's four PACU beds.
21:28
But it kind of just depends on, you know, as
21:30
a patient is waking up more, sometimes that monitor
21:33
shifts to the patient that's just coming out.
21:34
That's, you know, someone's awake and talking.
21:37
they're probably more fine than the person that's
21:39
still just coming out of general. So you have
21:41
to kind of allocate your resources and prioritize
21:44
your resources as needed. So tell me a story
21:49
or two about some different situations that you've
21:52
been in while you're there that required a different
21:55
plan than you would have maybe done if you had
21:59
more unlimited resources like you have here.
22:02
Yeah, I think there's definitely different scenarios
22:05
where... You just kind of have to be adaptable
22:08
and figure out what their norm is. On my trip
22:11
to Ghana, which I said was more regional focused,
22:14
we spent most of our time in their what they
22:17
call their accident and emergency operating theater,
22:19
which is a lot of ortho trauma and a lot of kind
22:22
of trauma based surgeries that come in through
22:25
their ER. Again, it's relatively unsafe to do
22:30
general anesthesia in a lot of these places.
22:33
So we'll never forget this little eight -year
22:35
-old girl who had broken her arm in a motorcycle
22:38
accident. And she was tearful, but in good spirits.
22:45
And they did a nerve block on her. They did an
22:48
infraclav block on her. No sedation, no warning,
22:52
just. poking her with a needle and she's crying,
22:55
screaming through it. But in the operating room,
22:57
she is wide awake, singing along to the music.
23:00
And, you know, they let her pick the music. And
23:02
in the U .S., an eight year old awake for surgery,
23:06
awake for a nerve block is unthinkable in most
23:09
places. So just kind of seeing that and realizing,
23:12
oh, like this is real different than what I would
23:15
see at a children's hospital at home was one
23:18
of those moments that I was like, oh, OK. I have
23:21
a seven -year -old who I consider to be a reasonably
23:24
tough kid, but would he be okay with getting
23:28
a completely unsedated infraclav? I don't think
23:32
so. Infraclavs are, like, sensitive, too. I mean,
23:35
she was small, but, like, you know, you got to
23:38
go through some muscle to get there. Yeah, that's
23:40
pretty impressive. Absolutely. Another time that
23:44
I had to definitely change my anesthesia plan.
23:50
Derek Florence and I went on a trip to Uganda
23:53
with Chad and his group a couple years ago. And
23:57
we actually decided we were going to stay for
24:01
a safari. So we flew separately from the rest
24:03
of the group. And we happened to get there. We
24:07
were supposed to get there 30 minutes before
24:08
them. So we were like, great, we'll start grabbing
24:10
bags. We'll see you all when you get here. We
24:11
aren't going to be the reason for the delay.
24:14
I start getting texts as we land from Katrina,
24:16
who says, hey. we've been delayed in rwanda it'll
24:22
be another hour before we get there okay fair
24:24
all right fine keep getting texts from katrina
24:26
hey we're getting more and more delayed hey we're
24:28
getting more and more delayed okay she's finally
24:32
like why don't you go find jeff which is the
24:33
local surgeon she was like you've been there
24:35
you know him you've met him he will get you guys
24:38
out of there you guys don't have to wait for
24:39
us our flight's gonna get cancelled um so They
24:44
had given Derek and I equipment bags of just
24:48
like gauze and some things that they were like,
24:49
well, you guys are more likely to get delayed
24:51
than us. So you take the, you know, the lighter,
24:54
less necessary equipment to have. We'll keep
24:57
the surgical equipment, the airway equipment,
25:00
that kind of stuff with us. And, you know, we'll
25:04
get you there. So we had our bags of gauze and
25:06
who knows what else that we didn't really, you
25:08
know, necessarily need for anesthesia purposes.
25:13
It's midnight and Jeff gets us to the house that
25:15
we're staying at. And he says, you guys just
25:17
want to come to the hospital with me tomorrow?
25:19
Like, you know, everyone else is stuck. We're
25:23
like, yeah, sure. That's what we're here to do.
25:24
He's like, great. I'll pick you up at eight.
25:26
Picks us up the next morning. He's like, I'm
25:28
just going to do a couple little surgeries. Do
25:30
you guys want to help out? Like, yeah, absolutely.
25:32
Like, why not? The local team who I had worked
25:36
with there before, Barbara, has become a good
25:38
friend to me. She's one of their medical officers.
25:40
She was there with some some of her trainees.
25:44
Jeff says, I'm just going to do a quick biopsy
25:46
of this guy's, you know, oral tumor, figure out
25:49
what it is. And, you know, it'll be a quick case.
25:55
You say, OK. Whenever I'm hearing these stories.
25:59
They always start with, oh, it's just going to
26:01
be a quick case. How many times have we heard
26:03
that anywhere? Many. Many. Our surgeons say that,
26:06
too. Surgeons don't necessarily understand quick
26:09
case. I was just in a 15 -minute case that lasted
26:11
about an hour and a half yesterday. Right. I
26:14
understand. Right. And most of the cases we do
26:16
in Uganda are big flap cases. My longest case
26:19
there has been 15 and a half hours. Oh, my gosh.
26:21
Quite lengthy. Definitely life changing. Wow.
26:24
But Jeff says this will be a quick case. He saves
26:27
generally his big giant cases for when his colleagues
26:29
are there that can help him out and have multiple
26:31
surgeons in the case. Sure. And so we induce
26:36
this guy has a normal external airway exam, I
26:40
should say, as well. Can't see anything of what
26:42
we're biopsying. So I'm like, OK, it's probably
26:44
something small. We induce this guy goes to sleep.
26:49
He's maskable. it's fine their team uh takes
26:52
a look uh under do because that's all they have
26:55
available and they're not able to get a view
26:57
i notice they start suctioning some blood out
27:00
of the airway that's a little weird but okay
27:03
um so they look again can't get a view uh so
27:08
either derek or i don't remember which one of
27:09
us first took a look and was like there's also
27:12
nothing here now there's 400 of blood in the
27:14
the canister oh my gosh just from the airway
27:17
just from the airway which we have not secured
27:19
at this point. Luckily, Snow Maskable, their
27:26
team goes to push a second dose of sucks because
27:29
it has been roughly 10 minutes that we are working
27:32
on this airway at this point. And I had to stop
27:34
them from A, redosing sucks, and B, I was like,
27:37
if we can't get this guy's airway, we can't give
27:40
him more paralytic. Maybe we need him to start
27:42
breathing again. We need him to wake up or, you
27:44
know. We have to get his airway. So I looked
27:48
at Jeff, the surgeon, and I said, I need you
27:49
to take this man right now. And he's like, what?
27:53
And I was like, seriously, I need you to take
27:54
this man right now. And they open up trach supplies
27:58
and we masked this man through a trach. Wow.
28:03
And after. His trach was in and Jeff was actually
28:07
able to take a look at his his equipment. This
28:10
man had a giant molecular tumor. which was the
28:15
reason we couldn't get a view and he had a lot
28:17
of bleeding. But it was a moment that I was like,
28:19
holy crap, like what would have happened if I
28:23
wasn't here to say that? And I'm hopeful that
28:25
things would have gone differently, but I'm not
28:27
100 % sure they were. The volykia, of course,
28:30
being the area right where you want to put the
28:33
tip of your blade when you're trying to intubate.
28:36
Yeah, yeah, which makes sense as to why he had
28:38
a normal external airway exam. That is scary.
28:43
So it sounds to me like this was a situation
28:47
where you made a pretty rapid call that saved
28:50
somebody's life. I'm hopeful, yes. And, of course,
28:55
we brought a McGrath and a Glidescope with us,
28:57
but it was stuck in Rwanda with the rest of the
28:59
team. And the other bag, of course. Excellent.
29:02
So what is it like collaborating with these people
29:05
like Jeff who work there and are used to that
29:09
sort of environment? What's the difference? between
29:12
your experiences everyone is typically very laid
29:15
back in all scenarios like even in that scenario
29:18
he did not seem like anything was emergent like
29:22
he worked quickly but you know it's just like
29:24
everyone is calm at all times i think they deal
29:27
with a lot of these emergencies more frequently
29:29
than maybe we do and can handle it appropriately
29:32
the funny thing is the last time i had been in
29:35
that same operating room in uganda with the same
29:38
team We left as they were doing an emergency
29:42
awake trach on that same bed. Oh, wow. The patient
29:46
was wide awake because it was an awake trach
29:48
respiratory distress and they anticipated difficulty.
29:51
But the very next time I was back, it was a masked
29:56
trach, emergency trach on that same bed. So kind
29:59
of seeing the flip side of the two scenarios
30:01
was kind of wild. So they're very good at handling
30:07
those sorts of emergency scenarios, at least
30:09
from the psychological perspective, you'd say.
30:12
I think so. Yeah. What are some differences where
30:14
you notice that maybe our team has a little bit
30:17
more expertise in? I think knowing when something
30:21
is going to go wrong, that anticipation of. you
30:24
know, this could be bad, um, where they were
30:27
going to try again and again to DL when it was
30:29
clear to me that we weren't getting any sort
30:31
of view and we're just getting more blood. And
30:32
eventually probably we're not going to be able
30:34
to mask this man, um, that either we were going
30:36
to have to wake him up or do a trach. And those
30:38
were going to be our two options. Um, so I just
30:41
think anticipating those definitely our airway
30:44
skills are more advanced. Obviously we also have
30:47
more advanced equipment. Here in the U .S., we
30:49
at UC here have McGraths and, you know, every
30:52
OR. So sometimes that's people's default. But
30:56
they don't have, you know, any of those video
30:59
equipments that could potentially save them in
31:01
scenarios such as that. So you are obviously,
31:05
to me, an excellent teacher. The residents always
31:07
really enjoy working with you, learning from
31:09
you, all these different things. What kind of
31:12
situations do you get to use your teaching skills
31:15
over there? Are you passing on some of the knowledge
31:18
that you have to some of the providers that are
31:20
over there? Yeah, absolutely. Like I said, in
31:23
Belize, it's more of a doing trip, but we regularly
31:26
take SRNAs and residents with us on those trips.
31:30
So they get to see kind of a different environment,
31:32
different thought processes. We do a pre -op
31:36
clinic day where, you know. You're screening
31:39
these patients, but you don't have lab results
31:41
or echoes or any sort of testing. It's how functional
31:44
can you be? What do you do for work? Do you get
31:47
chest pain with those kind of things? And you
31:49
have to make judgment calls based off of that.
31:52
So it's a different environment for the residents
31:54
and SRNAs that we take with us to learn. So we
31:57
don't just get to send them for their cardiology
31:59
consult. Unfortunately, no. Get a full million
32:01
-dollar workout. Unfortunately, no. But it tends
32:05
to work out just fine. And then in Africa, there's
32:10
a lot of teaching opportunity. They bring trainees
32:13
to the hospitals where they have groups coming
32:15
in, knowing that they're going to have that opportunity
32:16
for educational learning. And a lot of my teaching,
32:21
I like to do just about whatever scenario we're
32:23
in, because I think it's the easiest to learn.
32:26
in that modality, if you can relate it to something
32:28
that you're doing. But we've talked about doing
32:31
more formal education programs with the Uganda
32:34
curriculum as we get there and topics that they
32:36
are interested in with blocks for me and Josh
32:40
that frequently goes is critical care trained.
32:42
So he has a lot to teach as well. And in Ghana,
32:48
which I'm hopeful to go back to at some point
32:50
as well with the ASRA trip, I've been talking
32:52
to one of the coordinators there. They're very
32:56
interested in learning regional pain and even
32:59
chronic pain things. They actually have somebody
33:02
that's doing a fellowship in just pain, which
33:05
is acute and chronic there to learn all the procedural
33:07
stuff. And she wants to she's been teaching everyone
33:10
things that she learns from everybody else. So
33:12
it's really cool to see that kind of do one,
33:14
see one, teach one method throughout the process.
33:18
They even have a program through the World Society
33:22
of. Federation of Anesthesia, I think WSFA, I
33:25
think that's the correct acronym, where they
33:27
send trainees from other countries in Africa
33:29
to this hospital in Ghana to learn regional because
33:33
they have so much exposure through ASRA. ASRA
33:37
being? The American Society of Regional Anesthesia.
33:40
Thank you. Just for my audience who may not be
33:42
as aware of the acronym as you and I have gotten
33:46
more accustomed to. What about ultrasound availability?
33:49
Is that something that you have access to that
33:52
they have access to there? Are you bringing something
33:54
handheld? How does that all work? It really depends
33:57
where you're at. The hospital in Ghana that regularly
34:01
does their own regional procedures and is building
34:04
this fellowship and has people come train, they
34:06
do have an ultrasound. It is one of the, I think
34:10
it's a sonocyte. either m turbo or m max which
34:14
doesn't mean a lot to a lot of people but it's
34:16
one of those ones that like flips open like a
34:17
laptop and is kind of old school for a lot of
34:20
places here um but they have one of those readily
34:22
available um that is the only hospital that i've
34:26
ever been to internationally that has their own
34:28
ultrasound wow The hospital I went to in Uganda
34:32
for my regional trip had told us they were regularly
34:35
using ultrasound and regularly doing blocks.
34:37
So I thought, great, we'll be able to build on
34:40
that. Turns out they were regularly doing blocks
34:42
but had never seen an ultrasound before. So they
34:44
were doing landmark -based. anatomical blocks,
34:48
but had never seen an ultrasound before. So luckily,
34:52
Research International, the group that I had
34:54
went through, had sent an ultrasound with us
34:55
just in case, which was actually the same ultrasound
34:58
that I found in Ghana, which I thought was kind
35:01
of coincidental. But we had to teach them how
35:05
to use an ultrasound and how to find a needle
35:07
and all of that kind of stuff. So I went. had
35:10
a colleague go down to the market and bought
35:12
chicken breast. And we started playing with needles
35:15
and ultrasound on the chicken breast before we
35:18
started poking on patients. Yeah, it's definitely
35:21
good to block a chicken breast before you start
35:24
on the patients themselves. Yes. Yeah. So when
35:30
you left, though, the ultrasound probably also
35:33
went away too, right? Unfortunately, yeah. How
35:36
do you make sure when you're doing all this teaching
35:39
and telling people how to do the latest and greatest
35:43
thing, how do you make sure that your efforts
35:45
are having a lasting impact? Yeah, a lot of that
35:48
is figuring out what equipment they have available
35:51
and how to use the equipment they readily have
35:53
access to. Obviously, donations are great, but
35:58
they're not necessarily sustainable unless it's
36:00
a continuous donation pipeline. From a just resources
36:06
standpoint, talking to Obi, the fellow in Ghana,
36:10
they didn't have block needles there. She was
36:13
like, yeah, sometimes we get them when, you know,
36:15
people come through and do this kind of stuff,
36:16
but it's not something we can easily and affordably
36:18
get. So I asked her, you know, what they typically
36:21
use for doing their blocks. And the answer was
36:26
an IV needle, an 18 gauge for adults and 20 gauge
36:30
for children. Wow. Because that's what they readily
36:35
and cheaply have access to, where you and I would
36:39
never think of doing a block with an IV needle.
36:41
Not only because that's a larger size than we're
36:45
used to using. It's not a blunt tip needle, you
36:47
know, just different things that from a safety
36:50
perspective. But that is their norm and that's
36:52
what they train with because that's what they
36:53
can reliably get and use. Right. You worry about
36:57
things like cutting through nerves and all that
36:59
sort of stuff. You'd have to be a lot more careful.
37:02
Right. So just I was like, oh, I've never thought
37:05
of doing that. But that's, you know, their norm.
37:09
So just kind of adapting to teach with the equipment
37:12
they can readily and easily use is one of the
37:17
things that can be helpful. And then figuring
37:20
out, especially if you're going to go back to
37:21
somewhere regularly, you can figure out what
37:23
they need in. Uganda, one of the local anesthesiologists
37:28
has her own like pocket butterfly that she will
37:31
use for blocks, but that's her personal equipment.
37:35
Sure. So it just kind of depends. Some people
37:37
are willing to, you know, spend some of their,
37:39
you know, hard earned money for these things
37:41
and other places are not. So it just kind of.
37:45
kind of depends you know either building a fund
37:47
to donate money to get them the equipment that
37:49
they need um or bringing things that you can
37:51
leave behind i know um josh has actually found
37:54
multiple things on ebay um that we have left
37:57
in uganda um that he has generously you know
38:00
paid for out of his own pocket um an entitled
38:03
co2 monitor being one of those things that he
38:05
found on ebay uh because we didn't have entitled
38:08
monitoring in uganda entitle monitoring is one
38:13
of those things that is very important to an
38:16
anesthesiologist yeah i can imagine that it probably
38:20
makes a big difference to them yeah um so you
38:23
know a couple hundred dollars he was you know
38:26
able to donate that and leave you know that we
38:28
were able to teach them how to appropriately
38:30
use it and and what the numbers meant and all
38:32
of that kind of stuff where it's something that
38:33
they didn't regularly see but here it's one of
38:36
our uh standards of monitoring so yeah absolutely
38:40
that's something that i guess you more often
38:44
think about in the context of the history of
38:46
anesthesia is when they started adding things
38:49
like pulse ox and then tidal CO2 to make sure
38:52
that we can keep our patients safe. But when
38:56
you are going somewhere like you've been with
38:59
very limited resources, I guess you can't necessarily
39:01
take that stuff for granted. So what other memorable
39:06
moments do you have from your experience taking
39:10
these trips? That's such a broad question, John.
39:13
I have many. I know. And I've heard you tell
39:16
a lot of these stories before, but I just really
39:19
enjoy every time you come back hearing all the
39:23
new stories that you have. I think one of my
39:26
most just memorable patient stories was my first
39:32
trip to Uganda. We had a 17 -year -old who came
39:36
in for a head and neck. camp. He had a tumor
39:42
on his face. He had told everyone that he was
39:46
21 because he was still 17 and could not technically
39:49
consent for himself. But he had been largely
39:52
disowned by his family because of this tumor.
39:54
He had stopped going to school because he had
39:56
been made fun of so frequently. And it was very
40:01
disfiguring. It was mostly on his maxilla, kind
40:04
of in his nose and cheek region. But it's very,
40:09
you know, scary looking whenever you just see
40:11
it in general um so jeff had saved this case
40:17
knowing that the team was coming that it was
40:19
going to be a big procedure and he had uh told
40:21
this kid that he would you know help him out
40:23
as as best we could um so seeing his airway for
40:28
the first time i was still a resident on this
40:30
trip i was like holy crap this is terrifying
40:33
what do we do um and i you know i wish i could
40:37
show pictures and things on a podcast but makes
40:39
it a little tough, uh, in this modality. Um,
40:43
but we did a, you know, very thorough airway
40:45
exam and actually found out he had a great mouth
40:46
opening. Um, it was just all maxilla. Um, he
40:50
was a grade one view whenever you actually took
40:52
a look, um, at his Malin potty score or, uh,
40:56
yeah. And, um, but he was not going to be maskable.
41:00
Um, so we had to come up with a plan where we
41:02
could, um, you know, either rapid sequence intubate
41:06
or keep him spontaneously breathing and so we
41:09
figured out exactly what we needed to do airway
41:10
wise and luckily his airway you know wasn't that
41:13
terrifying it all ended up going very well he
41:16
had a 12 plus hour surgery where they created
41:19
a flap and removed this mass and And unfortunately,
41:24
his flap failed the first day, so we had to bring
41:27
him back to the operating room for a second 12
41:29
-hour procedure from a flap for the second day.
41:32
So this guy had, you know, two 12 -plus -hour
41:34
general anesthetics back -to -back. But his second
41:39
flap luckily took. He had a trach for about three
41:43
months, and then they were able to decannulate
41:44
him as he healed and is now back to living. you
41:48
know, a normal life. Um, luckily whenever they
41:51
sent the tumor to pathology, it was a non -cancerous,
41:53
just rapidly growing, uh, benign tumor. Um, so
41:57
he doesn't have to worry about, you know, well,
42:00
malignant cancer, um, happening there. Um, but
42:04
definitely a life -changing story and something
42:05
that I was like, holy crap, how does this even
42:07
happen? Um, kind of moment. Those sort of moments,
42:12
I imagine, make it all seem worth it when you
42:15
can make that big of a difference to somebody
42:17
who otherwise would have had a totally different
42:21
outcome to their lives. Absolutely. And when
42:25
I had talked to him beforehand and even after,
42:27
he said he wanted to be a doctor after all of
42:30
this. And he was a very smart kid, but he had
42:33
stopped going to school because he was being
42:35
made fun of and bullied. But now that he was...
42:39
back to living a normal life, he can, you know,
42:42
go and get the education and that kind of stuff.
42:44
So I'm hopeful to one day see him when I'm over
42:46
there as a, as a physician. Well, I look forward
42:49
to reading his personal statement. He applies
42:51
to our program. He can, he can probably name
42:56
drop you. Um, if somebody were in the early phases
43:03
of their career about to become a resident, or
43:06
maybe they're a resident already, and they think
43:09
that what you are talking about sounds amazing
43:12
incredible and that's a direction they want to
43:15
go with their career what recommendations do
43:17
you have for them um definitely let people know
43:21
you're interested it's one of those things that
43:22
a lot of global health stuff happens by word
43:25
of mouth i constantly get people reaching out
43:28
to me both other you know attendings from other
43:30
places that i've worked with saying like hey
43:31
what connections you have what do you know what
43:33
can i do or what programs can we grow Just letting
43:37
people know you're interested. I know when I
43:39
interviewed for residency here and Mike had talked
43:41
about the Belize trip, I was like, I am interested.
43:44
I want to do that. It's part of the reason that
43:46
I was interested in this program. And Mike knew
43:50
from the day one of me being an intern that I
43:52
was going to Belize and I was not going to have
43:54
it any other way as a CA3. And then COVID happened
43:57
and it almost ruined it, but we got to go. But
44:02
just letting people know you're interested, seeing
44:04
what opportunities are available. There's a lot
44:06
of different groups that go all over the world
44:09
that are big groups, both anesthesia as well
44:13
as surgical and just even medical wise. A lot
44:19
of it's kind of doing your own research or finding
44:20
out who knows what in whatever area you're in.
44:24
Mike redirects a lot of people to me now, which
44:26
is totally fine. But I've made a lot of contacts
44:29
through him. And that's also how I got involved
44:33
in Uganda. You know, Josh was like, hey, who's
44:36
who's interested? And I immediately jumped on
44:38
it. And now I've got to go back a couple of times.
44:41
So just letting people know you're interested
44:43
when those things come up, you know, things get
44:45
sent your way and somehow it ends up working
44:48
out. That's fantastic. What about. Any societies
44:53
that you recommend joining or being a part of
44:56
that have maybe been of help to you? What do
44:58
you think about that? I joined the ASRA, again,
45:02
the Anesthesia Society of Regional Anesthesia.
45:05
They have a global health special interest group.
45:08
I joined that. So they have a lot of little updates
45:10
here and there. They have a couple of different
45:12
trips that go various places. throughout the
45:17
world um so i'm trying to get a little bit more
45:19
involved in one of those and then actually one
45:21
of our colleagues here is uh trying to get his
45:23
uh brian's trying to get his tanzania trip i
45:26
think he actually has it recognized by azra now
45:28
oh that's great um so creating more opportunities
45:30
out there um and his is primarily a education
45:33
-based trip in um one of the hospitals in Tanzania.
45:37
So just getting involved like that, even if it's,
45:40
you know, doing a virtual lecture at first, trying
45:42
to, you know, get involved with that hospital
45:43
and then seeing what connections you can make.
45:46
If you're willing to do a lot of legwork, there's
45:48
definitely a lot of opportunities. If you want
45:50
something that's already a little more established,
45:52
there's definitely a lot of those things out
45:54
there too. So could you briefly talk about the
45:58
opportunities that our residents have if they
46:01
were doing a residency here? towards one of those
46:06
trips yeah absolutely um so here you see um we
46:10
take um usually three ca3s every year to belize
46:13
with us um that number can be flexed just kind
46:16
of depending on um how many trips there are in
46:19
different things um the group that we go to belize
46:21
with typically goes twice a year um for at least
46:23
three weeks among those trips so we definitely
46:25
have availability if we have enough staff to
46:27
to cover those trips for the residents um but
46:30
we There's usually a couple of residents, if
46:34
not more, that want to go on those trips. So
46:36
we have to figure out who has the time and availability
46:37
to spend some of their elective time doing that.
46:41
And then we also take residents on the Uganda
46:44
trip as well. Usually just one just because it's
46:48
a smaller trip overall and it's a lot farther
46:52
and more difficult to get to. And oftentimes.
46:55
10 to 14 days. So it's a little bit longer of
46:58
a time commitment and a little bit more of a
46:59
money commitment. But, you know, we help our
47:03
residents with some of the funding and the opportunity
47:06
and giving them the information that they need
47:10
to make those decisions. And it's always a very
47:13
positive feedback from the residents that get
47:15
to go. So I would love to be able to take all
47:18
of them if they all show interest. And it's something
47:21
that counts as real rotation time, right? It
47:24
does. We have it approved through the ACGME as
47:27
a recognized rotation for the CA3s. We just submit
47:31
a thing every year for the ones that are going
47:33
to get it approved for them. And it's seemingly
47:36
a pretty seamless process at this point, but
47:38
definitely something that can be done for a lot
47:40
of global health trips at other institutions
47:42
with a little bit of legwork as well. So what
47:45
kind of advice would you give to somebody who's
47:47
just about to take their first global trip? Be
47:51
ready to be adaptable and troubleshoot and be
47:54
prepared for everything. I know that seems silly,
47:58
but it's one of those things that you just never
48:00
know what's going to happen. I remember the first
48:03
trip I ever did. Me and Mary and Chris were in
48:06
the white van on the way up to the hospital,
48:08
and Mike was going through emergency scenarios
48:11
with us and said, if this happens, what are you
48:13
going to do? If this happens, what are you going
48:15
to do? And one of his scenarios was, if the power
48:19
goes out, what are you going to do? You know,
48:22
the power goes out here and the generator kicks
48:24
on. Right. Power goes out there. It's not a generator
48:28
to kick on. And we're all like, oh, that's not
48:30
going to happen. Lo and behold, happens to me.
48:34
Excellent. So you're already working with unfamiliar
48:37
equipment and in a situation where you've never
48:40
been in taking care of somebody's life is in
48:43
your hands and the power goes out. What are you
48:46
feeling in that moment? Oh, crap. But, you know,
48:49
a little more explicit, I think. Thank you for
48:53
sanitizing it for the podcast audience. Luckily,
48:57
you know, Mike had run through this. You know,
48:58
I think I would have been able to think through
49:00
it just a little slower, probably, if we hadn't
49:02
already talked about it. Luckily for me, it was
49:05
an ENT surgery where they had some headlights
49:06
on. So the room wasn't totally pitch black, but
49:09
it is a room without windows. So, you know, if
49:11
there were no headlights, it would have been
49:13
pitch black. I also popped on the. the light
49:16
on my cell phone, my flashlight and just laid
49:18
it so that it was flashing up. Luckily, the other
49:21
OR had just excavated and was rolling to PACU
49:24
when this happened. So at least their patient
49:26
was no longer under general, but obviously still
49:29
needed monitors. And switched over to an ambu
49:33
bag and was drawn up some propofol and Mary ran
49:37
in and said, what can I do? So I handed her the
49:40
propofol and said, I don't know, start being
49:42
an infusion pump. assign assign mary as the infusion
49:47
pump and you got to squeeze the bag so you guys
49:50
became the anesthesia machine correct um and
49:54
then last year uh john latrimoy and i were there
49:58
and i briefly ran through said scenario with
50:01
him and it happened to him It sounds like this
50:06
is actually a pretty high yield scenario to run
50:08
through. Yeah, it turns out. I think those are
50:10
the only two occurrences that I know for sure
50:12
it's happened. And luckily, it wasn't a long
50:15
power outage. It felt like it was forever. But
50:17
in reality, it was a couple of minutes. OK, so
50:19
it's something where the power did come back
50:21
on. You're able to turn everything back on and
50:23
it resolved. Yes. But you don't know, you know,
50:25
when it's when it happens. Apparently, one of
50:27
them was a planned power outage that no one had
50:30
told us about. You just didn't think to put planned
50:36
power outage as part of your anesthesia plan.
50:38
Right. Well, next time maybe you can consider
50:41
that. So now it's a scenario that is high yield
50:45
to run through for the residents going this year.
50:47
If you guys are listening, go ahead and plan
50:49
for that. Oh, excellent. So let's back up a little.
50:54
I'd love to hear some of the style points that
50:57
have helped make you more successful in your
51:01
life and career. Um, you know, I think just being
51:06
able to be adaptable, being able to work with
51:09
whoever you're working with in whatever scenarios
51:12
you're working with is is important. You know,
51:15
there's some people that are very rigid and probably
51:17
aren't the right people to to do these kind of
51:19
trips. The other thing is just being friendly
51:23
and social and communicating can go a long way.
51:26
Building relationships and having people trust
51:29
you and know who you are and coming into an area
51:32
that. you're not necessarily familiar with, um,
51:35
is super helpful. Um, I now have, you know, WhatsApp
51:39
messages going with, you know, Barbara and patients
51:42
and some of the other people in Uganda and I'm
51:45
Facebook friends with some of the people in Belize.
51:47
So, you know, just kind of keeping that rapport,
51:48
um, going, going back to the same locations.
51:52
Being willing to help and being adaptable and
51:55
doing whatever they need you to do. Sometimes
51:57
it's not just doing anesthesia. Sometimes it's
51:59
helping with a pre -op IV that they're having
52:01
trouble getting. Sometimes it's scrubbing because
52:05
they need somebody in the OR to scrub and we
52:08
have an extra person. So just kind of being adaptable
52:11
and ready to do anything and friendly and willing
52:14
to take whatever role you need to take goes a
52:17
long way. Well, when I think of. the people on
52:21
my short list of having high adaptability and
52:24
emotional intelligence and being friendly, you
52:27
are close to the top of that list. So thank you
52:29
so much for joining us. Absolutely. Anytime.
52:34
Thanks for joining us for this month's episode
52:37
of Style Points. If you found yourself particularly
52:39
interested in the topic of this episode, Erica
52:42
has offered to share her email address with anyone
52:44
who is interested in global health. For that,
52:47
or if you have any other thoughts, please email
52:50
me at stylepointspodcast at gmail .com, and I
52:53
would be happy to send that to you. I genuinely
52:55
appreciate everyone who has taken time out of
52:58
their day to listen to the podcast. If you really
53:00
enjoyed it, leave a five -star rating or a review
53:03
and share it with your friends. Lastly, take
53:06
a deep breath, open your eyes. We're all done.